MEDICARE: NICOLE ST JEAN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	07-1008337	IL

General Provider Information

NPI Number	:	1730592080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ST JEAN PSY.D.

Provider Business Mailing Address
First Line	:	4256 N RAVENSWOOD
Second Line	:	STE 217
City	:	CHICAGO
State	:	IL
Zip	:	60613-1114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4256 N RAVENSWOOD
Second Line	:	STE 217
City	:	CHICAGO
State	:	IL
Zip	:	60613-1114
Country	:	US
Telephone Number	:	847-834-9251
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	05/20/2015

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